PERSONAL DATA FORM

As part of our ongoing commitment to equal opportunities, Dixon Walter monitors the composition of all applicants. The information will be used solely for that purpose.

PERSONAL DETAILS

Please note that names must be precisely as shown on official document e.g. passport
Title: / Date of Birth:
First Name: / Gender: Female  Male 
Preferred First Name: / Nationality:
Middle Name(s):
Surname (Last Name):
Home Address:
Post/Zip/Area Code: / Home Contact Telephone Number:
Private E-mail (printed in capital letters -mandatory to receive IT logon details):
Correspondence Address (if different from above):
Post/Zip/Area Code: / Alternative Contact Telephone Numbers:
Alternative/Work E-mail:

EQUAL OPPORTUNITIES MONITORING

What is your ETHNIC GROUP? This data is used solely for monitoring purposes
Please tick the most appropriate box to indicate your background.
A White White
Gypsy or Traveller / B Mixed
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed background / C Asian or Asian British
Indian
Pakistani
Bangladeshi
Any other Asian background
D Black or Black British
Caribbean
African
Any other Black background / E Other ethnic group
Chinese
Arab
Any other Ethnic background / If you have ticked an ‘Other’ box, please write in the details below:
Information refused
Do you have a disability?
The Equality Act 2010 describes a disabled person as: “anyone who has a physical or mental impairment, which has a substantial and long term (for at least 12 months) adverse effect on his or her ability to carry out normal day-to-day activities.”
Using this definition, do you think you have a disability? Yes  No 
Information refused 

How would you describe your sexual orientation? This data is used solely for monitoring purposes
Please tick the most appropriate box to describe yourself;
Heterosexual
Homosexual
Bisexual
Prefer to self-describe (please confirm)…………………………………………………………….
Information Refused
Thank you for completing this form. Please sign below to indicate that the information provided is accurate and that you consent to Dixon Walter processing this data.
Signed / Date